Boards, Councils, and Committees Application

Pinellas County, Florida
Boards, Councils, and Committees Application

Suncoast Health Council

First Name *

Last Name *

Home Address

City

State

Zip Code

Home Phone

Email (a copy of what was submitted in this form will be sent to the email address listed below) *

You are a: *

Health Care Consumer

Health Care Provider

Health Care Purchaser

Are you currently a Pinellas County resident? *

Yes

No

If yes, for how long?

Are you registered to vote in Pinellas County? *

Yes

No

Occupation *

Title

Name of Business

Business Address

City

State

Zip Code

Business Phone *

Business Email

State your background, including your education, work experience, civic or community organization memberships and positions, and any professional licenses or memberships, and explain how this applies to the function of the board, council or committee: *

Are you currently serving on any Pinellas County boards, councils, or committees? *

Yes

No

If yes, please name.

Do you have or hold any employment or contractual relationship with any business or any agency which is subject to the regulation of or is doing business with Pinellas County? *

Yes

No

If yes, please explain.

Do you serve on any state, regional or local government boards, councils or committees? *

Yes

No

If yes, please explain.

Are you current with all taxes and any other financial obligations? *

Yes

No

If no, please explain.

Have you been convicted of a Public Entity Crime?
Public entity crime is defined by Florida Statute, sec. 287.133 as a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid, proposal, reply, or contract for goods or services, any lease for real property, or any contract for the construction or repair of a public building or public work, involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. *

Yes

No

If yes, please explain.

Have you been convicted of a financial felony? *

Yes

No

If yes, please explain.

Have you ever been convicted of a crime against children or seniors? *

Yes

No

If yes, please explain.

Are you currently, or have you ever sued Pinellas County? *

Yes

No

If yes, please explain.

Have you ever been arrested, charged, or indicted for violation of any federal, state, county, or municipal law, regulation or ordinance? (Exclude traffic violations for which a fine or civil penalty of $150 or less was paid) *

Yes

No

If yes, please explain.

The Pinellas County Commission strives to promote diversity and provide reasonable accommodations for individuals with disabilities. If you are requesting accommodation, please indicate below:

Resume (Click on the Upload button once your file is selected)

Important Information

Be advised that:
1. Membership on certain boards, councils or committees may have specific membership requirements, require an invoice of financial disclosure and/or require the submission of other information.
2. This application form, when completed and filed with Pinellas County, is a public record under Chapter 119, Florida Statutes and is open to public inspection.
3. The application must be completed in order to be considered for this board. The applicant is responsible for keeping information on the applicant current.
4. All material submitted to Pinellas County government is subject to the public records law of the State of Florida.

Thank you for your interest in serving on a board, council or committee for Pinellas County government. All board, council and committee meetings are open to the public. You are encouraged to attend a meeting to learn more about the duties of a member or the work of the board, council or committee in which you are interested.

If you have any questions regarding the completion and submission of this application or the duties and scope of responsibilities of the specific board, council or committee in which you are interested, contact the staff representative mentioned in the advertisement or listed in the committee listing.

I understand the responsibilities and commitment of time associated with an appointment to a Pinellas County board, council or committee. *

By clicking and submitting you have electronically signed this application and confirmed that the information provided is true and factual.